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Morwenna KirwanExercise & Behavioural ScientistFilex, 2012
All Stressed Out:Depression and the Role of Exercise
1 million Aust. Adults & 160,000 young people live with depression
1 in 5 females, 1 in 8 males will experience depression in their lifetime
Depressing Facts
depression in their lifetime Leading cause of suicide in Australia 2020 – depression will be 2nd largest global health
problem behind heart disease
A person may be depressed, if for more than two weeksthey have: felt sad, down or miserable most of the time OR lost interest or pleasure in
Depression Diagnosed
pmost of their usual activities AND
Experienced symptoms in at least threeof the following four categories:
Behaviours Thoughts
Stopped going out Not getting things done at work Loss of appetite or binge eating Withdrawn from family and friends Relying on alcohol and sedatives Stopped doing things they enjoyed
I’m a failure It’s my fault Nothing good ever happens to me I’m worthless Life is not worth living
Symptoms of Depression
pp g g y j y Unable to concentrate
Feelings Physical
Overwhelmed Guilty Irritable Frustrated Unhappy Indecisive Disappointed Miserable Sad/tearful
Tired all the time Sick and run down Headaches and muscle pains Churning gut Sleep disturbance Poor appetite/weight loss
Melancholic depression affects <5 % of Western populations severe depression – including low energy, poor concentration,
slowed or agitated movements
Types of Depression
Non-melancholic depression Most common type of depression Affects 1 in 4 women, 1 in 6 men in western world Linked to stressful events in person’s life in conjunction with
personality style
Psychotic depression
Non-specific response of the body to any stimulus that overcomes, or threatens to overcome, the body's ability to maintain homeostasis
Acute stress: temporary – we are capable
Stress
Chronic stress: ongoing hassle - unmanageable
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Response to Chronic Stress
Source: Adapted from Torres & Nowson 2007; Björntorp 2001.
• Depression is generally marked by hyperactivity of the HPA axis
• Exercise regulates the HPA axis response to stress• Not all depressed patients show HPA axis hyper-
Physiological Mechanisms
Not all depressed patients show HPA axis hyperactivity
• Older adults and women show hypo-activity
Use of antidepressants in the Australian population, 1975–2002
New = selective serotonin reuptake inhibitors, moclobemide, venlafaxine, nefazodone, mirtazapine, and reboxetine. Old = tricyclic antidepressants, monoamine oxidase inhibitors, mianserin, and nomifensine.
Selective Serotonin Reuptake Inhibitor Most widely prescribed anti-depressant in Australian & USA Act on serotonin levels -> serotonin helps regulate mood, but it
also plays a role in digestion, pain, sleep, mental clarity, and other bodily functions
SSRI Anti-depressants
other bodily functions. Symptoms improve following 4 to 6 weeks
SSRI names
•Fluoxetine (Prozac) •Fluvoxamine (Luvox) •Sertraline (Zoloft) •Paroxetine (Paxil) •Escitalopram (Lexapro)•Citalopram (Celexa)
• Low brain cell production of serotonin• Lack of receptor sites able to receive serotonin• Inability of serotonin to reach the receptor sites• Shortage of tryptophan chemical from which
Serotonin Imbalance Hypothesis
• Shortage of tryptophan, chemical from which serotonin is made
• Problem: we can’t measure serotonin levels in brain
SSRE – selective serotonin reuptake enhancer
SSRI – selective serotonin reuptake inhibitor
SNRI – selective serotonin norepinephrine reuptake inhibitor
Chemical Imbalance?
NDRI – norepinephrine dopamine reuptake inhibitor
60% Response Rate
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Only 60% of research conducted is published Published trials show anti-depressants more
effective than placebos Unpublished trials (40%) sponsored by drug
Placebo Effect
Unpublished trials (40%) sponsored by drug companies show no difference between drug and placebo
What do we really know? Anti-depressants do work ~ people get better Placebos do work ~ people get better No treatment ~ people stay same or get worst
SSRI antidepressants cause a wide range of side effects. SSRIs commonly make sleep disturbance/insomnia worse
initially, they are associated with improved sleep four to six weeks later
Side-effects of SSRI
Common side effects of SSRI anti-depressants:
•Nausea•Insomnia•Anxiety •Restlessness•Decreased sex drive•Dizziness•Weight gain or loss•Headaches
•Tremors•Sweating•Sleepiness •Fatigue•Dry mouth•Diarrhoea •Constipation
$150 billion industry
• 80% of which comes from patented drugs developed over the last ten years
• 14% of profit is spent on research and development as compared to 31% on marketing and administration.
“Depression is a heterogeneous disorder with a highly variable course, an inconsistent response to treatment, and no established mechanism. ”
Belmaker, R. H, 2008, Major Depressive Disorder, New England Journal of Medicine 358:55-68.
"The magnitude of benefit of anti-depressant medication compared with placebo ... may be minimal or nonexistent, on average, in patients with mild or moderate symptoms.
Magnitude of Effect
For patients with very severe depression, the benefit of medications over placebo is substantial.”
Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD (January 2010). "Antidepressant Drug Effects and Depression Severity". The Journal of the American Medical Association 303 (1): 47–53.
Alternative/adjunct to anti-depressants Equally as effective Benefits are long term Medication alone: 80% relapse within 2 years
Psychotherapy
Medication alone: 80% relapse within 2 years Psychotherapy: 25% relapse within 2 years 6 year mark: medication alone 90% relapse 6 year mark: psychotherapy 60% relapse
10 weeks of psychotherapy - 40% are depression free 6 years later
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• Meta-analysis – 23 trials, 907 participants• Comparing exercise with no treatment or control
group• Outcomes:
Exercise and Depression
Outcomes:• Exercise is more effective in treating depression than no
treatment• Exercise reduces depression symptoms than no
treatment• Exercise is as effective as psychotherapy and anti-
depressant medication
• increase levels of serotonin in the brain• increase endorphins, which are chemicals in the
brain with ‘mood lifting’ properties.• Increasing energy levels
How Exercise Helps Depression
Increasing energy levels• Helping to get a good night’s sleep• Providing distraction from worries and rumination• Providing social support and reducing loneliness if
exercise is done with other people• Increasing a sense of control and self-esteem, by
taking an active role in the individual’s own recovery
• Regeneration of brain cells
• Stress may suppress creation of new brain cells
A ti d t ti l t ti f
Neurogenesis
• Anti-depressants may stimulate creation of new brain cells
• Exercise stimulates new neurons
• Serotonin may be mediator
potential alternative to medication & electroconvulsive therapy painless with no known serious
side effects Based on neuroplasticity
Direct Current Stimulation (DCS)
ability of the brain to change throughout life based on experiences
long term depression weakening between two neurons
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Anti-depressants can cause hypo & hyperglycemia Anti-depressants can stop working Always encourage client to see GP Educate client that there are many types of
Important knowledge for PT
anti-depressants that work in different ways
Going on anti-depressants Up to 4 weeks of side effects: nausea, insomnia, vertigo
Going off anti-depressants Needs to be done gradually under GP supervision Withdrawal effects can be severe and affect ability to
exercise
Best advice for clients: If client is currently taking antidepressants - don’t stop
without consulting GP If client feels they are working, and are happy with results,
id ff t k k t ki th
Important knowledge for PT
side effects are okay ~ keep taking them If client has side effects, consult GP. Don’t stop taking them
– coming off anti-depressants has to be done gradually
No treatment is not a solution
Practice empathy Be aware of the symptoms of depression Always refer clients to GP
Take Home Message
Be a role model Manage your own stress Introduce mindfulness to clients Yoga and meditation
Be an active listener
Meditation/relaxation music from public library www.mindfulness.org.auGuided mindfulness soundtracks
www.actmindfully.com.au
Mindfulness Resources
Information on mindful techniques www.thehappinesstrap.com/Free chapter of book
www.blackdoginstitute.org.auInformation on depression and bipolar disorder
www.beyondblue.org.auInformation on depression, anxiety and related disorders,
available treatments and where to get help
Depression Resources
www.youthbeyondblue.combeyondblue’s website for young people
www.mmha.org.auMental health information for people from culturally diverse
backgroundsGP Referral – Mental Health Care PlanPsychologists – 5 to 10 sessions per year
SSRI• Nausea• Diarrhoea or
constipation
Side-effects of Anti Depressants
Tricyclic (TCAs)• Cardiac arrhythmia• Sedation• Dry mouth
• Insomnia or tiredness• Anxiety or nervousness• Decreased libido and
abnormal ejaculation• Dry mouth
y• Constipation• Nausea• Increased or decreased
appetite• Weight gain
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Monoamine OxidaseInhibitors
• Increased BP• Dizziness
Side-effects of Anti Depressants
Norepinephrine & Serotonin Reuptake Inhibitors• Sedation• Increase blood pressure
N• Headache• Sleep disturbance• Weight gain• Sexual dysfunction• Gastrointestinal disturbances
• Nervousness• Insomnia• Decreased appetite• Constipation or diarrhoea• Abnormal ejaculation
1. Defusion: distancing from and letting go of unhelpful thoughts, beliefs, memories and other cognitions
2. Acceptance: making room for painful feelings, urges and sensations, and allowing them to come and go without a struggle
Benefits of Mindfulness
struggle3. Contact with the present moment: engaging fully with our
here-and-now experience, with an attitude of openness and curiosity
4. Spacious awareness: accessing a spacious sense of self – the observing self: a transcendent aspect that is conscious of thoughts and feelings as passing experiences, but not identified with them.
Practicing mindfulness helps you: to be fully present, here and now to experience unpleasant thoughts and feelings safely to become aware of what you’re avoiding
Benefits of Mindfulness
to become more connected to yourself, to others and to the world around you
to become less judgmental to increase self-awareness to become less disturbed by and less reactive to unpleasant
experiences to learn the distinction between you and your thoughts
Benefits of Mindfulness
Practicing mindfulness helps you: to have more direct contact with the world, rather than
living through your thoughts to learn that everything changes; that thoughts and
f li d lik th thfeelings come and go like the weather to have more balance, less emotional
volatility to experience more calm and
peacefulness to develop self-acceptance and
self-compassion
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